Are you looking to track the physical capabilities of your employees? If so, there is an easy way to do that - creating a physical capabilities form. A well-structured form can provide employers with information about employee health and fitness levels which are essential for informing decisions on tasks and job roles assigned at work. With this blog post, we’ll guide you through how to create a comprehensive physical capabilities form that documents all the data required from your employees to ensure compliance with regulatory requirements as well as help you better manage workplace safety procedures.
| Question | Answer |
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| Form Name | Physical Capabilities Form |
| Form Length | 1 pages |
| Fillable? | No |
| Fillable fields | 0 |
| Avg. time to fill out | 15 sec |
| Other names | physical capability form, ny estimated capabilities, ny physical capabilities state form, ny estimated physical state pdf |
IName of Physician |
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IName of Employee |
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Note: Important |
Information |
on Reverse |
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3TRUCTIONS: If the employee |
is found to be 50% or less disabled, please complete |
this form based on your estimation of |
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),islher current physical capabilities. |
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1. |
Medical Diagnosis: |
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2 a. In an |
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Sit |
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o Continuously |
o With Rests |
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Stand |
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0304 |
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o Continuously |
o With Rests |
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Walk |
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o Continuously |
o With Rests |
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b. In a given day, for how many total hours can this employee sit, stand, and/or walk in combination? |
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D 4 |
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D 6 |
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0 8 |
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010 |
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0 12 ' |
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D 16 |
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3.Other Capabilities: (Please check appropriate boxes.)
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Never |
0ccasonaI IIv |
FreauentlvI |
Contlnuouslv |
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Lift |
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Upper extremities: |
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O Right |
O Left |
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Which hand is dominant? |
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Can this employee perform |
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repetitive actions such as: |
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Carrv |
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Simple |
Pushing |
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Fine |
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Grasping |
& Pulling |
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Manipulation |
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RIGHT |
OVes |
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No |
DVes |
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No |
DVes |
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No |
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LEFT |
DVes |
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No |
OVes |
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No |
DVes |
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No |
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md |
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dQuat |
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Lower Extremities: |
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I Crawl |
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Use of feeVlegsfor repetitive movement, as in |
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Climb |
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0 |
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operation of foot controls and motor vehicles. |
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Run |
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Reach above |
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Simultaneous |
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Extremity |
Extremity |
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shoulder level |
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Operate a |
D |
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OVes |
0 |
No |
DVes |
0 No |
OVes |
0 No |
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motor vehicle |
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4. |
Work Environment Restrictions: |
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Can this employee: |
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Be exposed to marked changes in temperature and humidity? |
0 Ves |
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No |
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Be exposed to unprotected heights? |
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0Ves |
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0 No |
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Be around moving machinery? |
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0Ves |
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0 No |
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5. |
Other Restrictions: |
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0Ves |
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0 No |
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Can this employee restrain combative clients? |
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0 No 0Ves |
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Does this employee have any visual or hearing impairment requiringaccommodation? |
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If "Yes, " |
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please |
explain: |
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6.Based on your examination(s) of this employee, are there any known problems of a general nature, including any medications
prescribed for the diagnosis listed, that would interfere with this employee returning to work?
O No 0 Ves If "Yes,"please explain:_
'Vhen,in your estimation, will this employee be ready to return to full duty? Date |
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;omments: |
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TelephoneNumber |
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